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cao a e <br /> STATE OF CALIFORNIA W poi' <br /> STATE WATER RESOURCES CONTROL BOARD a ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE -- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Orvdkr�# cam,.•«•�. <br /> ADDRESS /I NEAREST CROSS STREET PAflCELN(OPTIONAt) <br /> CITY NAME STATE 21P CODE SITE PHONE#WITH AREA CODE <br /> jr. CA Zo9 <br /> TOI/ BOX INDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR / RESERVATION V IF INDIAN a OF TANKS AT SITE E.P.A. I.D.N(oplianal) <br /> 0 3 FARM 0 4 PROCESSOR I,_—!d/5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE,#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NN ( FIRST) PHONE WITH IGHTS: AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4l-dL N..R fy <br /> MAILING OR STREET ADDRESS ✓ box bindbab 0 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sc Le, S zr— <br /> MAILING OR STREET ADDRESS ✓ wx bimicalb [7 INDIVIDUAL O LOCAL AGENCY L�] STATE-AGENCY <br /> =CORPORATION = PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 U <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ ma bintlbaU 0 1 SELF-INSURED =12 GUARANTEE 0 3 INSURANCE 0 4 SURETY SONO <br /> L-15 LETTER OF CREDIT O 6 E%EMPTION 99 OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TIRE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Du/O <br /> 3 ? TT O Y <br /> LOCATION CODE OPT7AL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF S RMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIgNs <br /> / FOR0033A RS <br /> �f'�, <br />